The big news is that as early as 2017, the UNLV campus could welcome its first class of medical students through a historic partnership with the University of Nevada School of Medicine (UNSOM), established at UNR in 1969. It’s big because the move sets aside an era of backbiting between north and south, and because the successful, long-term development of the fragmented statewide school into two independent institutions in Reno and Las Vegas is projected to boost the economy and health care resources across Nevada.

Cries for a public medical school in Southern Nevada have been building practically since the decision to base UNSOM up north was made. UNR had more than 80 years of infrastructure on UNLV, and the populations of Reno and Las Vegas were a lot more comparable back then.

Now, Las Vegas is the nation’s largest metro area without an allopathic (M.D.) medical school—unless you count UNSOM’s “two-plus-two” model of foundational teaching on the Reno campus and clinical training predominantly in Las Vegas hospitals. Proponents of the new school vehemently don’t and insist that not having one dedicated to Southern Nevada impacts the standard and availability of health care. But something even more impactful is referenced in the memorandum of understanding about the med school expansion, signed by the presidents of UNLV and UNR, UNSOM’s dean and the chancellor of the Nevada System of Higher Education (NSHE) on November 6 and unanimously approved by the NSHE’s Board of Regents on December 5: “The funding of the critical residency and fellowship training needed in the state will also need to be considered,” the MOU states, calling for an implementation plan that strikes “the necessary balance of undergraduate and graduate medical education.”

“If you have a limited ability to invest, as the state does, where do you put your money to get the biggest impact?” asks Dr. Thomas Schwenk, dean of UNSOM and one of the architects of the MOU. “I could make a pretty good case that we’d be better off to put relatively more money into graduate medical education [GME].”

Schwenk sees the need for two full medical schools, but asserts, “… there’s no point in doing a pipeline of medical students if we don’t have the GME at the end to serve them.”

Medical students are not doctors, and their contributions to health care are as limited as their expertise. Medical residents, on the other hand, are doctors, and analysis by the Association of American Medical Colleges shows that about 50 percent practice in the states where they were trained. Schwenk says that UNSOM grads who do residencies in Nevada have an 80 percent chance of staying.

It matters because Nevadans want a return on their tax dollars, and because doctor-to-patient ratios are highest in the healthiest states. In the AAMC’s 2013 report on the physician workforce, Nevada ranks 46th for the number of residents and fellows, with 10 per 100,000 people, compared to No. 1 Massachusetts’ more than 80. Those ranks are echoed in regard to overall numbers of active physicians, and if you cross-reference that list with CDC stats on life expectancy and the annual America’s Health Rankings report, you see a lot of the same states in the top 15. Nevada? We’re just not there.

With 335 allopathic and 84 osteopathic (D.O.) positions, Nevada’s residency landscape isn’t just small, Schwenk says, but lacks crucial specialties and varies in quality, mostly due to poor support. Medicare reimbursements are a big part of the funding equation, with the rest coming from the state and partner hospitals and practices where programs are based. Southern Nevada has an unusual density of for-profit hospitals, which Schwenk says could be part of the problem. “Some hospitals believe that you can ‘make money’ with GME; that’s not even remotely true. You can sometimes come close, but as a hospital you have to believe that this is important because it improves the quality of care, or it gives you a pipeline of new medical staff members, or it gives you some competitive advantage.” He says that for-profit hospitals generally don’t see training as part of their job, leaving GME to universities and public and county hospitals. “There are some for-profit hospitals, however, who are interested in starting to talk about this, and I think there may be opportunities like that in Las Vegas developing over time,” Schwenk says. “But it’s still going to cost somebody something.”

Cost is obviously a hurdle in Nevada. Schwenk says political and economic mire has resulted in a long period of “fairly flat or even declining funding” for medical education. That doesn’t play well for the MOU’s reference to GME expansion, which includes a plan for 170 new M.D. residencies in specialties we need, everything from orthopedic surgery and urology to pediatrics and geriatrics. These programs would cost about $30 million a year—equal to the state’s annual investment in everything UNSOM does. Add the untold millions it will cost to grow the Reno campus and build a new one in Las Vegas, while tackling the dearth of care in rural communities, and you begin to understand what Schwenk and his fellow visionaries are up against.

“It’s a pretty expensive proposition, but this is what happens when there’s been relatively little investment over the years. I’m not saying that I am not appreciative of the $30 million the state puts into medical education now, but it’s just so inadequate compared to the needs.”

Seeing those needs encouraged Dr. Mitchell Forman in the 2004 founding of Touro University Nevada, a private (meaning no state funding) medical school that trains osteopathic physicians and other health care professionals on its Las Vegas campus. Touro’s groundbreaking alliance with for-profit Valley Hospital created those 84 D.O. residencies, including some specialties Nevada lacked entirely, according to Forman. The school has identified half a dozen other local hospitals that, at least on paper, have the bandwidth to start residency programs, but Forman says hesitation may tie to uncertainty about the Affordable Care Act. Medicare reimbursements for GME are expected to drop in the new system—just as it adds up to 473,971 newly insured Nevadans. As Forman says, “That’s insane.”

He’s from New York, which the AAMC ranks No. 2 for residents/fellows and No. 3 for active physicians per capita. The Northeast in general has higher doctor-to-patient ratios and better health stats compared to the West, but Forman believes the region can catch up, especially with more collaboration and creativity.

Primary care, for instance, is an area of incredible need across the country. Forman says the way primary care residents are trained could be simultaneously more cost-effective and truer to their everyday working environment once they become attending physicians.

“When you think about what primary care physicians do, we take care of patients as outpatients; it’s not in a hospital. It’s preventative medicine and it’s primary care outside of hospitals. Well, if you think about how we train most of our residents, it’s hospital-based training, which is very expensive,” he says. So Touro’s leadership is exploring progressive options like community health centers and consortiums, involving partnering and pooling resources among hospitals and smaller clinics so the cost of residencies is more spread out and the hands-on training more diverse.

Touro grads enter both osteopathic and allopathic residencies, and Forman hopes the MOU’s vision for GME bolsters their options across the spectrum of specialties. He thinks the state should consider an existing model that requires doctors who complete programs in Nevada to practice in Nevada or refund the cost of their training.

“The truth is, we all want the same thing,” Forman says of different approaches to medicine and to making Nevada healthier. “I think we have to very aggressively seek out GME partners in the community, identify hospitals that have the capacity to develop GME programs, and put some pressure on them to do that. … Once you have the infrastructure GME, then you can talk about growing medical schools. I’m not saying that’s not a good idea. But I’m saying in terms of putting the cart before the horse, if you want to develop your future, studies have shown over and over again—physicians practice within 50 miles of where they train. So you must have those GME programs. What we’re doing now is paying through the public sector for graduates of the allopathic program to leave the state.”

In the end, they might anyway. Decisions about where to train and practice are a lot more complicated than program availability, and Nevada’s health picture doesn’t boil down to one element of care. But the ripples are powerful. The least we can do is give the next generation of doctors more of a choice.